Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?

Abstract

Background Despite over a decade of efforts to reduce the adverse event rate in healthcare, the rate has remained relatively unchanged. Root cause analysis (RCA) is a process used by hospitals in an attempt to reduce adverse event rates; however, the outputs of this process have not been well studied in healthcare. This study aimed to examine the types of solutions proposed in RCAs over an 8-year period at a major academic medical institution. Methods All state-reportable adverse events were gathered, and those for which an RCA was performed were analysed. A consensus rating process was used to determine a severity rating for each case. A qualitative approach was used to categorise the types of solutions proposed by the RCA team in each case and descriptive statistics were calculated. Results 302 RCAs were reviewed. The most common event types involved a procedure complication, followed by cardiopulmonary arrest, neurological deficit and retained foreign body. In 106 RCAs, solutions were proposed. A large proportion (38.7%) of RCAs with solutions proposed involved a patient death. Of the 731 proposed solutions, the most common solution types were training (20%), process change (19.6%) and policy reinforcement (15.2%). We found that multiple event types were repeated in the study period, despite repeated RCAs. Conclusions This study found that the most commonly proposed solutions were weaker actions, which were less likely to decrease event recurrence. These findings support recent attempts to improve the RCA process and to develop guidance for the creation of effective and sustainable solutions to be used by RCA teams.

Root-cause analysis: swatting at mosquitoes versus draining the swamp

“…Kellogg et al 7 report policy reinforcement among the most prevalent corrective actions stemming from RCAs. For example, after investigating a case in which a surgical sponge was left inside the patient, the RCA team concluded that the organisation's policy for counting equipment was effective and that human error was to blame.…”

“…Returning to the example highlighted by Kellogg et al ,7 the multiple cases of retained surgical sponges over the 8-year period raise the question: is counting not being performed well or does counting just not work well? Disguised observation can address the first option.…”

“…So, the reality consists of hospitals trying to ‘cure’ these systems problems on the basis of a multidisciplinary group of volunteer clinicians meeting a few times after an RCA, often with little relevant expertise. That hospitals mostly choose to resolve RCAs merely by promoting a policy or recommending more education and training7 should thus not come as a surprise.…”

“…In this issue of BMJ Quality and Safety , Kellogg et al 7 confirm these concerns about RCAs. Reviewing 302 RCAs conducted over an 8-year period at a US academic medical centre, the authors report the most common solution types as training, process change and policy reinforcement.…”

Root Cause Analysis Gone Wrong

“…Despite its popularity, whether RCA improves patient safety remains unclear . For example, a recent longitudinal mixed‐methods study investigating 302 RCAs during an eight‐year period showed that similar adverse events, such as retained foreign objects during surgery, recurred after RCA recommendations were implemented …”